Case study of "Smokey" (suspected Haemobartonella felis) written for VPI-VBMA\’s Student Case Study Competition. (Winner, RUSVM Chapter, 2012)

1. Margaret Cantrell
Ross University School of Veterinary Medicine
Class of 2014
margaretcantrell@students.rossu.edu
Competition coordinator – Sophie Russell

2. “Smokey” Cantrell
12 October 2010
SUBJECTIVE
Smokey is an 8 YO spayed female domestic short hair feline weighing 3.86 kg. The owner reported that the pet
had not been eating well for about 2 weeks and has been lethargic for several days. The owner was unsure if the
pet had been drinking water, as the dish is shared between the pet and two dogs. The owner also reported that
to the best of his knowledge, the pet has had no vomiting or diarrhea. Upon presentation, the pet was
depressed, icterus was noted at the ears, nose, sclera, and mucous membranes, and the hair coat was unkempt.
OBJECTIVE
The pet was presented for evaluation of anorexia and lethargy. Temperature was 100.5ᵒF and weight was noted
to be 3.86 kg. Smokey is not on any medications, including flea/tick/heartworm prevention. The only
abnormality noted on physical examination was icterus. Neurologic examination revealed that all cranial nerves
are intact, and no neurologic abnormalities were noted. In-house biochemistry revealed a slightly elevated
blood glucose (149 mg/dL, normal 70-130 mg/dL), elevated ALP (358 U/I, normal 0-90 U/I), and low BUN (9.8
mg/dL, normal 15.0-32.0 mg/dL). Values for creatinine, ALT, and total protein were within normal limits.
ASSESSMENT
Based on clinical presentation and biochemical analysis, a differential list of hepatic lipidosis, hemolytic anemia,
and Haemobartonella felis was made. To help minimize the differential list, additional blood work was sent to an
outside lab for a complete blood count and smear. These tests revealed a stress leukogram, thrombocytosis, and
slightly decreased hemoglobin (9.3 g/dL, normal 9.5-15 g/dL). An increased RDW was also noted on CBC (27.4%,
normal 14.0-18.5%), but on microscopic examination, it was found that both WBC and RBC morphology were
normal. The blood smear did not demonstrate H. felis organisms, but because ALT is not significantly increased,
along with the presence of both icterus and anemia, H. felis is the primary differential for this case.
PLAN
Due to poor condition on presentation, it was recommended that the pet remain at the clinic for observation for
2-3 days. Though the pet was not noted to be dehydrated, 200 mL of LRS was administered subcutaneously on
the day of presentation as a precautionary measure. Additionally, 0.75 mL of Baytril and 0.5 mL of prednisone
were given to control the suspected hematological disorders. When the pet was released to the owner 3 days
later (on 15 October 2010), prescriptions for doxycycline (25 mg/mL) and prednisone (8 mg/mL) were filled and
sent home, with 1 mL of each to be administered twice each day for one week, at which time the pet will need
to return for a recheck.
22 October 2010
SUBJECTIVE
Recheck appointment. Owner reports that the pet is still not eating well, and that it has been difficult to

3. administer medication to the pet, and as a result, there have been several missed doses over the past week. The
pet is still very icteric and coat is unkempt, though hydration status appears to be normal.
OBJECTIVE
Physical examination revealed that icterus is still present and appears to have worsened. Weight was noted to
have decreased since the last visit, and is now 3.64 kg. Temperature was recorded at 101.7ᵒF. In-house
chemistry and PCV were done. ALP has increased since presentation (594 U/I, normal 0-90 U/I), and ALT is also
slightly elevated (101 U/I, normal 0-85 U/I), and BUN has further decreased (7.6 mg/dL, normal 15.0-32.0
mg/dL). PCV has dropped since the last visit (from 26.9% to 24.8%, normal 25.0-45.0%), though it is only slightly
below the range. Values for blood glucose, total protein, and creatinine were all within normal limits. CBC
revealed lymphocytopenia (1.0 x 103/µL, normal 1.8-7.0 x 103/µL), monocytosis (1.7 x 103/µL, normal 0.2-1.0 x
103/µL), and mild granulocytosis (13.1 x 103/µL, normal 2.8-13.0 x 103/µL), in addition to an increased RDWa
(38.5 fl, normal 20.0-35.0 fl) and RDW% (26.0%, normal 14.0-18.5%). Platelet count is improved since last visit,
and is now within normal limits.
ASSESSMENT
Clinical signs appear to have worsened since the last visit. Additionally, an insignificant increase in ALT alongside
continuing icterus and anemia continues to support a tentative diagnosis of H. felis. Hepatic lipidosis can be
ruled out due to the absence of a significant increase in ALT.
PLAN
Though thrombocytosis has resolved, other abnormalities in blood work and worsening icterus indicate that the
pet still needs to continue treatment. Differential list still includes hepatic lipidosis, hemolytic anemia, and H.
felis, though hemobartonellosis is more strongly suspected. The pet was given ¾ mL Depo-medrol IM and was
sent home with 22.7 mg Baytril, to be given SID for 7 days. The owner was instructed to keep a close eye on the
pet, and to encourage the pet to eat. Recheck in one week is recommended, at which time another CBC will be
done.
29 October 2010
SUBJECTIVE
Recheck appointment. Owner reports some improvement since last visit, stating that the pet has been eating,
though only a few bites each day. Owner also stated that the pet has not been hiding as much, and no doses of
medication have been missed since the last visit.
OBJECTIVE
On physical examination, icterus was noted to still be present, though it does appear to have improved since the
last visit. Weight has continued to decrease, and is now 3.30 kg. Temperature was recorded at 99.6ᵒF, and PCV
has increased since last visit (24.8% to 27.1%, normal 25.0-45.0%). In-house CBC was done, and noted a
continued mild lymphocytopenia (1.7 x 103/µL, normal 1.8-7.0 x 103/µL), monocytosis (1.9 x 103/µL, normal 0.2-
1.0 x 103/µL), and increased RDW% (23.4%, normal 14.0-18.5%). All other values were within normal limits.
ASSESSMENT
Continuing resolution of clinical signs suggest that the animal is recovering. Of concern, however, is continued

4. weight loss, which will need to be monitored closely in the coming weeks. Icterus, though still present, seems to
be resolving. This, in conjunction with an increased PCV since the last visit, strongly suggests that the patient’s
condition is improving.
PLAN
Because icterus has not yet resolved, treatment will be continued. The pet was given ¾ mL Depo-medrol IM, and
was sent home with instructions to be given 22.7 mg Baytril to be given SID for 14 days, at which time the pet
should return for a reassessment. Because weight has continued to decrease, the owner was instructed to
encourage the pet to eat, and to notify the clinic with any further concerns.
12 November 2010
SUBJECTIVE
Recheck appointment. Owner reports that the pet has been eating some since the last visit, and that there have
been no issues in administering medication. Additionally, icterus appears to be resolving.
OBJECTIVE
Physical examination revealed that icterus is present, though appears to be less noticeable than at the previous
visit. The pet’s weight was recorded at 3.30 kg (same as last visit). In-house CBC revealed a continued mild
lymphocytopenia (1.7 x 103/µL, normal 1.8-7.0 x 103/µL) and monocytosis that has increased since the last visit
(from 1.9 x 103/µL to 2.3 x 103/µL, normal 0.2-1.0 x 103/µL). Likewise, RDW% has increased since the last visit
(from 23.4% to 24.3%, normal 14.0-18.5%). Anemia is continuing to resolve, with PCV recorded at 27.5% at this
visit, compared to 27.1% at the prior visit (normal 25.0-45.0%).
ASSESSMENT
Recovery appears to be progressing smoothly, as anemia and icterus are resolving, and weight has been
maintained over the past two weeks. Lymphocytopenia and monocytosis may be attributed to the suspected
haemobartonellosis.
PLAN
Though resolving, the continued presence of icterus necessitates continuing treatment. As such, the owner was
instructed to continue giving 22.7 mg Baytril SID for 14 days, at which time the pet should return for a recheck.
29 November 2010
SUBJECTIVE
Recheck appointment. Owner reports that the pet appears to be feeling better, as evidenced by fractious
behavior, which owner states is normal for the pet. Owner also reports that the pet has been “ravenously
hungry” since the last visit.
OBJECTIVE
Physical exam revealed that icterus is almost completely resolved. PCV was noted to have improved since the
last visit, increasing from 27.5% to 29.3% (normal 25.0-45.0%). CBC also revealed a continuing mild
lymphocytosis (1.4 x 103/µL, normal 1.8-7.0 x 103/µL), increased RDW% (24.5%, normal 14.0-18.5%), as well as

5. thrombocytosis (570 x 103/µL, normal 200-500 x 103/µL) and slightly decreased MPV (7.7 fl, normal 8.0-12.0 fl).
Additionally, the pet has lost weight since the last visit, and was noted to be 3.18 kg.
ASSESSMENT
Icterus has almost completely resolved and PCV has risen to an acceptable level, and as a result, it would appear
that the haemobartonellosis has resolved. However, based on the new discovery of a ravenous appetite couple
with continued weight loss, it is possible that the pet has developed either steroid-induced appetite stimulation
(as a consequence of Depo-medrol administration) or has hyperthyroidism. A T4 panel was sent to an outside
laboratory to rule out hyperthyroidism. T4 was found to be within normal limits at 1.3 µg/dL (normal 0.8-4.7
µg/dL).
PLAN
Because the haemobartonellosis appears to have resolved, Depo-medrol injections are no longer necessary, and
the owner was told to discontinue use of Baytril. Based on the normal T4 value, it may be said that the pet is not
a hyperthyroid patient, but it cannot be ruled out indefinitely. If the pet does, in fact, have hyperthyroidism, the
normal value could be due to euthyroid sick syndrome, or the pet could be in the early stages of the
hyperthyroidism. In order to confirm, further testing (i.e., evaluation of free T4 or a T3 suppression test) would
need to be performed in several weeks, once we can be fairly certain that there are no interfering factors
present. At this time, owner declined such tests. A recheck in 3-4 weeks, at which time a PCV should be obtained
to determine if all hematological values have returned to normal.

16. VPI PET INSURANCE CLAIM FORM
NO COVER SHEET NECESSARY. Fax to: 714-989-5600 No.of pages: 1
Take this form to your veterinarian to complete Section 2. Veterinarian’s signature not required.
1 POLICYHOLDER INFORMATION 2 Fill in below. ONE CLAIM FORM PER PET. You must submit
itemized receipts. You must provide us with veterinary medical records
when we request them. Claims that are NOT COMPLETE or MISSING
POLICY NO: itemized, legible receipts or invoices may be delayed.
PET NAME: "SMOKEY" CANTRELL
WELLNESS TREATMENT HOSPITAL/
BREED: DSH TREATMENTS DATE CLINIC
AGE: 8YO
Wellness Exam / /
NAME: JOE CANTRELL
Annual Lab Tests / /
ADDRESS: 114 SHARONVIEW ST.
CITY: FORT MILL
Vaccinations / /
STATE: SC ZIP: 29715 Dental / /
PHONE (H): (803) 548-1133
Spay/Neuter / /
PHONE (B):
EMAIL:
Heartworm/Flea Medication / /
DIAGNOSIS(ES)
TREATMENT HOSPITAL/
Please provide a diagnosis, or a tentative diagnosis,
not a description of services performed. DATE CLINIC
HAEMOBARTONELLA (MYCOPLASMOSIS) 10 / 12 / 10 FORT MILL ANIMAL CLINIC
HAEMOBARTONELLA (MYCOPLASMOSIS) 10 / 22 / 10 FORT MILL ANIMAL CLINIC
HAEMOBARTONELLA (MYCOPLASMOSIS) 10 / 29 / 10 FORT MILL ANIMAL CLINIC
HAEMOBARTONELLA (MYCOPLASMOSIS) 11 / 12 / 10 FORT MILL ANIMAL CLINIC
HAEMOBARTONELLA (MYCOPLASMOSIS) 11 / 29 / 10 FORT MILL ANIMAL CLINIC
HYPERTHYROIDISM 11 / 29 / 10 FORT MILL ANIMAL CLINIC
/ /
3 TOTAL AMOUNT SUBMITTED 5 MAIL:
FAX: OR VPI Claims Department
$ 470.00 (Preferred Method) PO Box 2344, Brea CA 92822
PLEASE DO NOT USE STAPLES, PAPER CLIPS OR TAPE
714-989-5600 to attach receipts or invoices to your claim form.
You must submit receipts for all veterinary service charges. All
submitted fees may not be eligible for coverage. Fees that exceed Visit the VPI Policyholder Portal at my.petinsurance.com
benefit schedule limits are your responsibility.
to download claim forms, view claims status and more.
By signing this Claim Form, I confirm that to the best of my
knowledge the information I have provided is true and correct. I
VPI DOCUMENT CENTER CLAIMS NOTES (VPI use only)
authorize the release of my pet's medical records to Veterinary Pet USE ONLY
Insurance Company/DVM Insurance Agency.
4 POLICYHOLDER SIGNATURE and DATE
X / /
CF-1(08-09) ©2009 Veterinary Pet Insurance Company 10RET928

17. FAX ONLY THE FRONT OF THIS CLAIM FORM. NO COVER SHEET REQUIRED.
CLAIM FORM CHECKLIST ✓
❑ I entered in my policy number, pet information and my contact information.
❑ This claim form includes only one pet.
❑ My veterinarian helped me complete Section 2 with the diagnosis(es),
treatment date and the name of the hospital/clinic.
❑ I included all of my itemized and legible receipts/invoices.
❑ My pet's name and policy number are clearly identified on each
receipt/invoice.
❑ I added up all my eligible receipts and entered the Total Amount Submitted.
❑ I signed and dated this claim form. (My veterinarian is not required to
sign this form.)
❑ I submitted this claim form and all supporting receipts/invoices to the VPI
Claims Department. I understand that claim forms that are incomplete or
missing itemized and legible supporting receipts/invoices may be delayed.
❑ I kept a back-up copy of all documentation submitted for my records.
❑ If medical records are requested to process this claim, I understand that it is
my responsibility to provide them to VPI.
Two ways to submit your claim:
Fax 714-989-5600
– OR –
VPI Claims Department, PO Box 2344, Brea, CA 92822
If FAXING your claim, DO NOT MAIL IT IN. Duplicate claims submission may delay processing.
Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information
or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties.
Not applicable in Nebraska, Oregon and Vermont.

18. VPI® MAJOR MEDICAL PLAN BENEFIT SCHEDULE
SECTIONS USED FOR CALCULATION OF CLAIM REIMBURSEMENT
A B
Primary Secondary
Code Diagnosis Allowance Allowance
INFECTIOUS (Virus, Bacteria, & Fungus)
Conditions
2008 Haemobartonella (Mycoplasmosis) $350 | $140
ENDOCRINOLOGY
Conditions
2921 Hyperthyroidism $720 | $290

19. INVOICE
2921 A

2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
2008 A
INELIGIBLE
Invoice total: $470.00

20. CLAIM CALCULATION
BASED ON INVOICE AND BENEFIT ALLOWANCES
VPI® Major
Eligible veterinary Eligible
Conditions Veterinary Fees Annual deductible Medical Plan
fees1 Amount
Benefit Allowance
Haemobartonella
$42000 -$10000 $31700 $35000 $31700
(Mycoplasmosis)
Hyperthyroidism $5000 $5000 $72000 $5000
Invoice total: $47000 Total reimbursement: $36700
Reimbursed fees: $367 00
Fees paid out-of-pocket: $10300
Fees incurred without insurance: $470 00
1
$300 boarding fees are ineligible for coverage; $42000 veterinary fees - $10000 deductible - $300 ineligible fees = $31700
eligible veterinary fees